Addressing threats to health care's core values, especially those stemming from concentration and abuse of power. Advocating for accountability, integrity, transparency, honesty and ethics in leadership and governance of health care.

Wednesday, June 29, 2016

It's deja vu all over again. I even get to reuse the introduction of a post from one month ago. As I wrote in May, 2016,...

The problem of ever rising, amazingly generous pay for top health care managers is a frequent topic for Health Care Renewal.
We have suggested that the ability of top managers to command ever
increasing pay uncorrelated with their organizations' contributions to
patients' or the public's health, and often despite major organizational
shortcomings indicates fundamental structural problems with US health,
and provides perverse incentives for these managers to defend the current system, no matter how bad its dysfunction.

In particular, we have written a series of posts about the lack of
logical justification for huge executive compensation by non-profit
hospitals and hospital systems. When journalists inquire why the pay of
a particular leader is so high, the leader, his or her public relations
spokespeople, or hospital trustees can be relied on to cite the same
now hackneyed talking points.

It seems nearly every attempt made to defend the outsize compensation
given hospital and health system executives involves the same arguments,
thus suggesting they are talking points, possibly crafted as a public
relations ploy. We first listed the talking points here, and then
provided additional examples of their use.
here, herehere,here, here, and here, here and here.

They are:
- We have to pay competitive rates
- We have to pay enough to retain at least competent executives, given how hard it is to be an executive
- Our executives are not merely competitive, but brilliant (and have to be to do such a difficult job).

Yet as we discussed recently,
these talking points are easily debunked. Additionally, rarely do
those who mouth the talking points in support of a particular leader
provide any evidence to support their applicability to that leader.

Bit at least most journalists who inquire into hospital executive
compensation used to make an attempt to be "fair and balanced" by also quoting
experts who question the talking points.

But not so much lately,...

Million Dollar Plus Hospital CEOs in New York

The Journal News, based in the northern New York City suburbs, ran a series of articles about executive pay and perks at NY hospitals and hospital systems. The main aricle in the series is here. A listing of the five highest paid hospital officials is here. A listing of executive perks, and conflicts of interests affecting the hospitals' and hospital systems' board members is here. The main article began,

Perks at the nonprofit hospitals included first-class plane tickets, chauffeurs and country club memberships. Severance and retirement payments mirrored golden parachutes awarded to for-profit corporate executives.

The article noted that 112 people who worked for non-profit hospitals in the Lower Hudson valley earned more than $1 million. The biggest pay went to the top executives of the biggest systems:

Bonuses and payments spiked the highest among executives at the helm of major hospital consolidations, data show.

North Shore University Hospital’s President/Chief Executive Officer Michael Dowling topped the list in 2014. He was paid $10.1 million in salary, bonuses and other pay. That is compared to $3 million in 2010.

Dowling’s payments came as the Long Island hospital and its affiliated organization, then North Shore-LIJ, began its ongoing expansion.

The health system, now Northwell Health, has pushed into the Lower Hudson Valley, partnering with Northern Westchester Hospital in Mount Kisco and other regional providers.

Also,

Dr. Steven Safyer, president and CEO of Montefiore Medical Center in the Bronx, was paid nearly $4.9 million in 2014, including a bonus of $1.3 million.

That's an $800,000 increase from the $4.1 million he was paid in 2010. It came as Montefiore bought bankrupt hospitals in Mount Vernon and New Rochelle, and pushed its expansion northward into Westchester County, which now includes a partnership with White Plains Hospital.

Note that Dr Sayfer also was given a hospital-paid car and driver.

An accompanying article noted the three other highly paid CEOs in New York state, Warren Hern, CEO of Unity Health Systems in Rochester, $7,490,213; Mark Clement, CEO of Rochester General Hospital, $5,323,856; and Dr Steven Crowin, CEO, New York Presbyterian Hospital, $4,591,728 [who also benefited from a policy allowing first-class or business airfare for flights over 6 hours, and some form of housing allowance.)

Furthermore, the next week the Journal News publised an op-ed by William Mooney, CEO of the Westchester County Association, which was devoted to defending the pay of his fellow CEOs. It started with indignation against anyone who would question the pay of our fearless leaders,

While it is fashionable to cast aspersions on high-income earners, the arguments set forth about the compensation levels of area health-care CEOs are misguided and erroneous.

Then Mr Mooney again hit the talking points.

We have to pay competitive rates

We have to pay enough to retain at least competitive executives

Given that a hospital is a community organization, the compensation of their executives is decided by boards made up of community members who base their decisions on research, competitive market analyses and responsible financial projections.

Our executives are brilliant

Running a hospital is a business unlike any other. First and foremost, hospitals are complex organizations that are about protecting and promoting health, and saving lives.

Also,

A hospital CEO is responsible for overseeing and guiding his or her staff through a maze of financial and regulatory challenges while making sure safety and performance standards are at the highest possible levels.

Third, the technology and infrastructure enhancements that today’s hospital CEO must manage are vast and rapidly changing. The staffing required to support all of these disparate functions encompasses a wide range of skill sets and education. A hospital CEO must understand and manage all of those roles, and must keep an eye on the demands and responsibilities of maintaining new technology.

In addition, the op-ed concluded with the argument:

your readers would be better served by reporting on the qualitative and quantitative benefits our community derives from having the best health-care leaders in the nation at the helm of our local hospitals.

And these leaders to more than manage finances. The op-ed implied that hospital CEOs are personally responsible for savings lives. This can be seen in the quote above under the brilliance argument, and later:

Non-profit status is conferred upon an organization that does something for the public good. Saving lives clearly is in the public’s best interests!

This despite the fact that the majority of CEOs in the article above, and indeed the majority of top managers of hospitals and hospital systems are not health care professionals, and cannot take any direct responsibility for patient care. This also despite the assertion by Mr West, the senior attorney for the New York Council of Nonprofits, that "hospitals are run like a business,..."suggesting that the people running them might put money, not "doing something for the public good," first.

Also, note that while Mr Mooney extolled the community based boards whose members made such discerning decisions about executive pay, he did not address these members' numerous conflicts of interests. For example, re some of hospitals and hospital systems with the most highly paid CEOs,

Stephen Friedman was a board member of Memorial Sloan-Kettering in 2014 when the cancer center paid $10.5 million for architectural services from Perkins/Eastman. Friedman’s brother-in-law, identified as Mr. Perkins, is affiliated with the firm, tax filing show. Bradford Perkins is listed as the co-founder and chairman of Perkins/Eastman, according to its website.

Jamie Nicholls was a Memorial Sloan-Kettering board member in 2014. Her spouse was a co-founder of King Street Capital Management, which the hospital paid nearly $700,000 for management fees, tax filings show.

And,

White Plains Hospital disclosed one business transaction involving an interested person. The filing has few details. It reported the name of the interested person as 'Donor #24' and the relationship with the hospital as a 'substantial contributor.' The amount of the transaction was $15,350,345, and the description is 'BUS TRANS.'

Kaleida Health in Buffalo paid $121,660 to the Greater New York Hospital Association for participation dues in 2014. James Kaskie, former president and chief executive officer at Kaleida, was also a board member at the association, tax filings show.

Finally, note that neither the main article nor Mr Mooney's op-ed cited any evidence, even anecdotal, that these particular leaders are so brilliant, or that their hospitals are better than average, even in terms of finance, much less actual care of patients.

No Challenges to the Talking Points

The main article did not include any dissenters who questioned expansive executive pay. An accompanying editorial in the Journal News could only muster some anemic concern. It called multi-million dollar compensation for local non-profit hospital system executives "unsettling." It did contrast ever rising executive pay with the difficulty patients have paying their bills. But it could only muster conclusions that mirror the talking points:

Hospitals are quick to defend their executives' rising compensation, and their arguments are good ones. Chief among them is that hospitals must compete for the best top officials, including with for-profit hospitals across the U.S. They say they need to attract and keep leaders who can competently oversee growing health-care systems, meet ever-changing government regulations and improve patient care and satisfaction.

So, all they called for was disclosure of compensation:

Hospital executives deserve fair pay for hard work; taxpayers deserve to know that resources are being used to attain quality care for all.

Although Mr Mooney seemed to see "aspersions" in the article, and thought "the article implies that hospital CEO compensation is somehow responsible for the continued rise in healthcare costs," and argued that "hospitals do not deserve to have nonprofit status," I could find no such challenges in the Journal News series to the notion that top non-profit hospital managers deserved every penny they got.

Conclusion

Sadly, the ever rising compensation of top health care managers seems to inspiring less, rather than more skepticism in the media. No more is it true that nearly all articles that try to delve into executive compensation at all
at least quote some experts who are skeptical of current practices.

The Journal News series included no such attempts at balance.
In my humble opinion, while it reported on useful facts, the opinions it contained leaned towards propaganda for managers' current privileged position in health care.

Despite all the blather about how top hospital executives deserve millions of dallars, there are real reasons to be skeptical. As we discussed here,
there is a strong argument that huge executive compensation is more a
function of executives' political influence within the organization than
their brilliance or the likelihood they are likely to be fickle and
jump ship for even bigger pay. This
influence is partially generated by their control over their
institutions' marketers, public relations flacks, and lawyers. It is
partially generated by their control over the make up of the boards of trustees
who are supposed to exert governance, especially when these boards are
subject to conflicts of interest and are stacked with hired managers of
other organizations.

While Mr Mooney was indignant that high executive pay may be considered a reason that hospital charges and health care costs are rising, he did not even discuss the argument that the current method of determining such pay may provide perverse incentives to grow hospital systems to achieve market domination, raise charges, and increase administrative bloat. As an op-ed in US News and World Report put it about executive pay in general,

But the executive pay decisions made inside corporate boardrooms have an enormous impact in the outside world. Outrageous pay gives top executives an incentive to behave outrageously. To hit the pay jackpot, they'll do most anything. They'll outsource and downsize and make all sorts of reckless decisions that pump up the short-term corporate bottom line at the expense of long-term prosperity and stability.

So I get to recycle my conclusions from my last post in this series....

We will not make any progress reducing current health care dysfunction
if we cannot have an honest conversation about what causes it and who
profits from it. In a democracy, we depend on journalists and the news
media to provide the information needed to inform such a discussion.
When the news media becomes an outlet for propaganda in support of the
status quo, the anechoic effect is magnified, honest discussion is
inhibited, and out democracy is further damaged.

True health care reform requires ending the anechoic effect, exposing
the web of conflicts of interest that entangle health care, publicizing
who benefits most from the current dysfunction, and how and why. But it
is painfully obvious that the people who have gotten so rich from the
current status quo will use every tool at their disposal, paying for
them with the money they have extracted from patients and taxpayers, to
defend their position. It will take grit, persistence, and courage to
persevere in the cause of better health for patients and the public.

The American Medical Association’s new president, Andrew W. Gurman, MD, known for his affability and quick wit, is not one to seek out controversy.

In an interview before being sworn in this week as the AMA’s annual meeting in Chicago, IL, Gurman said he has no agenda for his tenure at the top of the organization.

Considering the mass hatred of EHRs by physicians (and nurses), the issue of EHR-related harms, compromised patient data security, physician scorecards, and other noxious issues, maybe he should have an agenda. E.g., see my Jan. 28, 2015 post "Meaningful use not so meaningful: Multiple medical specialty societies now go on record about hazards of EHR misdirection, mismanagement and sloppy hospital computing" at http://hcrenewal.blogspot.com/2015/01/meaningful-use-not-so-meaningul.html.

... Though physicians’ anger over the frustration of using existing electronic health records was a major topic of conversation at the [annual AMA] meeting, Gurman said he had little to add other than no one could make him use one.

“I don’t have an EHR,” he said. Due to the fact that he runs his own practice he found it easier and cheaper just to forgo the enhanced payments he would get under the federal “meaningful use” regulations for converting to electronic records. “I just take the penalties,” he said.

Not every physician can afford the time sink most EHRs represent, and the increasing penalties for non-users, unfortunately.

Perhaps on the AMA agenda should be a return to sense regarding physician and nurse documentation, with significant reduction in their clerical burden for starters.

A former nursing executive at Sonoma West Medical Center in
Sebastopol, Calif., has filed a lawsuit against the hospital, alleging
she was fired after raising concerns the EMR was a threat to patient
safety, reports The Press Democrat.

Autumn AndRa, RN, was serving as CNO of the hospital when she
approached CEO Ray Hino and said the EMR, called Harmoni, was unsafe,
according to the report.

Ms. AndRa was reportedly terminated from her CNO position April 14
and was offered a position in the intensive care unit, which her
attorney Daniel Bartley told The Press Democrat would have been a demotion. Ms. AndRa left the hospital due to alleged harassment, according to Mr. Bartley.

If these allegations are true, a clinician, the Chief Nursing Officer, was shown the door in an act of recklessness for her complaining about bad health IT.

Deliberate indifference is the conscious or reckless
disregard of the consequences of one's acts or omissions. It entails
something more than negligence, but is satisfied by something less than
acts or omissions for the very purpose of causing harm or with knowledge
that harm will result.

A wrongful termination lawsuit was apparently filed:

... The lawsuit alleges the EMR system mixes patients' records, so
information in one patient's chart moves to another patient's chart. It
also alleges the EMR has issues tracking and updating patient
medications and does not display patient code status information, which
informs providers of patients' desired medical interventions, according
to the report.

These types of gross defects, if true, represent an on its face menace to patient safety.

Mr. Hino told The Press Democrat the EMR did not pose any danger to patients, and no patients have been harmed because of software defects.

Like most others uttering that line, as I've documented, Mr. Hino apparently lacks expertise (e.g., in clinical, IT or Medical Informatics domains) to render such a judgment about patient danger if the EHR did or does exhibit such problems. His bio is at https://www.linkedin.com/in/raymondhino.

As to whether patients were harmed, that is irrelevant if the EHR has such defects. Sooner or later, they will be. The issue is risk, not body counts (yet).

There's also this. The EHR in question is not the product of the major EHR vendors but the work of apparent insider. See http://about.harmonimd.com/usa/ referencing just two implementations, one at Somona West Medical Center, California, the subject of this post, and one at the Kilimanjaro Christian Medical Centre, Tanzania, Africa:

... The lawsuit also names Dan Smith, the developer of the EMR software in
question, as a defendant. According to the lawsuit, Mr. Smith "has
engaged in retaliation against [Ms. AndRa] and other employees who have
voiced concerns that Mr. Smith's electronic medical records system, his
self-dealing, and his management of medical and financial decisions are
not in the best interests of SWMC and pose life-threatening risks to
patient care," reports The Press Democrat.

Not only did Mr. Smith develop the software in question, but he is a
significant financial backer and influencer at SWMC. According to a 2015 report from The Press Democrat,
Mr. Smith and his wife have contributed nearly $9 million to the
hospital in donations and forgivable loans, and he plays a role in "ever
major decision" regarding the hospital. Mr. Smith is on SWMC's board of
directors.

I really don't think injured or dead patients (or juries) will find those relationships an excuse for bad health IT, what seems like a clinical trial of new IT by a private company and owner without informed consent (including divulging to patients and users a possible COI), and the discharge of someone complaining about it.

Mr. Smith and hospital officials declined to comment on the lawsuit, citing pending litigation, according to the report.

"Private Information"- information about behavior that occurs in a
context in which an individual can reasonably expect that no observation
or recording is taking place, and information which has been provided
for specific purposes by an individual and which the individual can
reasonably expect will not be made public [45 C.F.R.46.102(f)] )][2]

"Identifiable information"- specific information that can be used to identify an individual[2]

Human subject rights

In 2010, the National Institute of Justice in the United States published recommended rights of human subjects:

There is a disconnection between the FDA’s drug approval
process and the reports we see in medical journals. Pharmaceutical corporations
exploit this gap through adulterated, self-serving analyses, and the FDA sits
on its hands. I suggest we need a new mechanism to fix the problem – by independent
analyses of clinical trials data.

When they analyze and publish their clinical trials in
medical journals, pharmaceutical corporations have free rein to shape the
analyses. The FDA conducts independent analyses of the data submitted by the
corporations, and it may deny or delay approval. But the FDA does not challenge
the reports that flood our medical journals, both before and after FDA approval.
It is no secret that these publications are routinely biased for marketing
effect, but the FDA averts its gaze. That failure of the FDA – a posture known
as enforcement discretion – has been well documented. The
question is why? At the same time, exposing the biases has been difficult for
outsiders because the data are considered proprietary secrets.

A Case Study

Now, a detailed example of deliberate corporate bias has finally
been documented, through materials released in litigation. This exposé was
reported by Drs. Jon Jureidini, Jay Amsterdam, and Leemon McHenry. Their
findings were recently published, and their article is freely
available on-line. This example concerned a clinical trial of an
antidepressant drug in children and adolescents. The drug, citalopram, was
already approved for use in adults, and its off-label use in children would spread
if there was published supportive evidence. An Investigational New Drug (IND)
protocol and plan of analysis were filed by Forest Laboratories with the FDA in
1999. The trial was completed in 2002, and the results were published
in American Journal of Psychiatry in 2004 – but the FDA did not accept the
results as sufficient to approve this drug for use in children or adolescent
patients. By that time the patent on citalopram had expired and Forest
Laboratories introduced a virtual twin drug, escitalopram (single active enantiomer).
That more expensive version of citalopram was heavily promoted, and it was
approved in 2009 for use in children, but even then the FDA specifically noted
that safety and efficacy were not established in children under age 12. Since
then, new
analyses suggest that most antidepressant drugs have little evidence of
efficacy even in older children.

Tricks of the Trade

In service of a positive report, the statistical analyses
performed by Forest Laboratories deviated from the IND plan of analysis, and
negative results were edited out. The biases now documented by Dr. Jureidini
and his colleagues for that 2004 sponsored report
in American Journal of Psychiatry included:

·Inflating the main
measure of the drug's effect by reporting an incorrect and clearly exaggerated
effect size. On being challenged, the authors
later explained their misinformed
computation without actually acknowledging the error.

·Failure to report
secondary measures of response because they were negative. Those measures had
been stipulated in the IND protocol to serve as cross-checks on the main result.
These negative findings were airbrushed out of the publication by corporate
marketing.

·Unplanned, new
secondary measures of response were inserted ex post facto because they were positive (that is a real no-no).

·Violations of the
IND protocol were not reported and were then fudged (patients who had properly
been excluded per protocol were put back in for analysis, which made a
nonsignificant primary outcome analysis turn positive).

·Adverse events were
analyzed and summarized in a misleading way.

·The finding that
the drug had no effect on depression in children under age 12 was not reported,
even though an age-effect interaction analysis had been specifically projected
in the IND protocol. This strategic omission left the impression that off label
use of citalopram in younger children could be clinically reasonable.

·The corporation knew that another, unpublished,
trial in children, conducted by their European partner Lundbeck was negative,
and that it raised concerns about suicide risk, but that information was
withheld. The authors later were challenged
in the journal about this concealment. Their response
was utterly disingenuous.

·The published article failed to acknowledge that
it was authored by a non-medical ghostwriter, who took direction from marketing
executives – the 2004 publication was a marketing product purporting to be an
objective scientific report.

·Academic authors were recruited only after the
manuscript was written, reviewed, and approved in-house – these nominal
academic authors were signed on to front for the corporate narrative.

·The perfunctory role of the academic (ahem) authors
is clear from the fact that they failed to recognize the wildly inflated effect
size claimed for the drug – something that was instantly obvious to several
groups of competent
readers.

The Payoff

These changes created the appearance of a positive result,
and the publication drew wide attention. According to Thomson Reuters Web of
Science, it has been cited over 160 times, placing it in the top 5% of cited
articles in clinical medicine from 2004. This early publication gave plausible
justification for off-label use of citalopram/escitalopram in children, even
with FDA approval having been denied, and even though the trial was actually
negative. The FDA has
reported that between 2005 and 2010 well over 750,000 patients up to age 17
received escitalopram, including almost 160,000 under age 12. Thus, the sleight
of hand about failure to show even fudged efficacy in younger children is
especially deplorable. Internal memoranda reproduced in the exposé by Dr.
Jureidini and his colleagues give a clear picture of the corporate manipulation
of the scientific publication process. Now we know – in black and white – just
how bad the bias can be. This kind of data manipulation, with ad hoc cherry picking and moving of
goalposts, is unacceptable, but it is entrenched. Indeed, it is business
as usual – and the FDA looks
away.

A Specific Proposal

Our primary defense against such perversions of scientific
reporting is fidelity to the registered IND protocol and plan of statistical analysis.
The solution is not hard to see: We need independent analyses of clinical
trials because we cannot trust the corporate analyses. In effect, we need something
like the Underwriters Laboratory to verify the statistical analyses of clinical
trials. Nobody takes the manufacturing corporation’s word for it concerning the
safety and performance of X-ray machines or cardiac defibrillators. Why treat the
statistical analysis of drug trials any differently? It’s highly technical work.

Who should assume that responsibility? Why not the FDA? After
all, they alone see all the data. My specific proposal is for Congress to
mandate that the FDA analyze all clinical trials data strictly according to the
registered protocols and analysis plans. That requirement should apply to new
drugs or to approved drugs being tested for new indications. It should apply
also to publications reporting new trials of approved drugs. Corporations and investigators should be
prohibited from publishing their own in-house statistical analyses unless
verified by FDA oversight.

Why Bother?

There are three good reasons for prohibiting in-house corporate
analyses of clinical trials data. First, as the present example illustrates,
the inherent conflict of interest is simply too great to be ignored. Second, when
corporate statisticians who answer to marketing executives get “creative” in
the ways exposed here, then the conditions for valid statistical analyses no
longer apply – the statisticians are then on a fishing expedition and they are
no longer testing the defined study question with fidelity to the methods
specified in the IND protocol. In that case, any nominally significant statistical
findings are just exploratory, not actionable – not good enough to justify off-label
use of the drug, especially when properly evaluated alternatives are available.

Third, there can be no justification for treating the
production of influential publications in medical journals any differently than
we treat the production of potent drugs. Our FDA continuously inspects
production facilities for evidence of physical adulteration, even as far away
as China. They now need to monitor the adulteration of clinical trials reports
in medical journals. The harms of adulterated analyses can be just as serious
as the harms of adulterated products.

Push Back from
Pharma?

We can expect the pharmaceutical industry to mount a First
Amendment challenge to this proposal. It will fail, because the public health
is too important. Just as there is no First Amendment right to shout fire in a
crowded theater, so also corporations have no First Amendment right to say a
drug is safe and effective when they know it isn’t. That is a betrayal of
patients.

The corporations will also claim piously that their
publications undergo peer review. Sadly, that is no barrier to this pervasive corporate
bias because the peer reviewers for medical journals don’t see all the real
data – they see only the data the corporation wants them to see. Only the FDA sees
all the data. We can no longer cling to the myth of informed and unbiased peer
review of clinical trials reports. The corporations rely on that myth as a fig
leaf to support their First Amendment claims and to defend their practice of
in-house statistical analyses. Moreover, medical journals also are subject to
bias and conflict of interest. We could note that the Associate Editor of
American Journal of Psychiatry in 2004 was also a major U.S. key opinion leader
for Forest Laboratories. According to one of the released depositions, he was
instrumental in securing acceptance of the report by the journal.

Business as Usual?

The present example is not an isolated case. Dr. Jureidini
and his co-authors described several similar, recent examples. One of those was
the reanalysis by
Jureidini and others of an infamous
trial of paroxetine for pediatric depression. And still, fresh exposés keep
appearing. The latest is from Lisa Cosgrove at the University of Massachusetts
in Boston and her colleagues, involving “ghost management of the information
delivery process” for another new antidepressant drug, vortioxetine – available
on-line here.
(What is it with the antidepressants, anyway?) On this Health Care Renewal
blog, Roy Poses has called attention to these issues. As recently as June 8,
2016 he discussed
the Transparency International report on corruption in the pharmaceutical
sector.

Eric Topol, who helped
to expose the Vioxx scandal, made similar points recently in a BMJ commentary: “The bad science
in clinical trials has been well documented and includes selective publication
of positive results, data dredging, P hacking, HARKing, and changing the
outcomes that were prespecified at the beginning of the study….Furthermore, the disparity between what appears in peer
reviewed journals and what has been filed with regulatory agencies is long standing
and unacceptable.”

It’s No Time for Old
Solutions

As the eye-popping numbers
of children treated with escitalopram show, even off-label use of an
undistinguished drug in a niche population can be highly profitable. That is
why I am proposing that the statistical analysis of clinical trials data can no
longer be entrusted to pharmaceutical corporations, on account of their massive
inherent conflict of interest. Open access to patient level data, as well as pre-registration
of protocols and of data analysis plans, have been actively promoted for some
years now to clean up the corporate bias in clinical trials. These are positive
developments, but they will not close the disconnection highlighted just above
by Dr. Topol. The once idealistic world of clinical trials has changed irreversibly
in the past 30 years. As one observer has noted,
“… in the course of time the coordinated
actions of industry, government, and the biomedical research community have
degraded the basic rules of empirical science…” We would do well to
acknowledge this fact, and to recognize with Abramson and
Starfield that “The
first step is to give up the illusion that the primary purpose of modern
medical research is to improve Americans’ health most effectively and
efficiently. In our opinion, the primary purpose of commercially funded
clinical research is to maximize financial return on investment, not health.”

When corporations are
involved, there is no point in prolonging the myth of noble and dispassionate
clinical scientists searching for truth in clinical trials. It’s over. We would
do better to stop pretending that corporate articles in medical journals are
anything but marketing messages disguised with the fig leafs of coöpted
academic authors and of so-called peer review. The case study reported out by
Drs. John Jureidini, Jay Amsterdam, and Leemon McHenry shows us the real face
of business as usual in commercial clinical trials. That being the case, it
makes no sense to expect corporations and academic key opinion leaders suddenly
to reform their biased and conflicted behavior. Only a structural change from
the outside like I propose here has any chance of succeeding. The statistical
analysis of clinical trials is too important to be entrusted to the sponsoring
corporations.

It is time for Congress to
grasp this nettle. The time for enforcement discretion is past, and we need Congress
either to direct the FDA to act or to create a new mechanism of oversight. To
do nothing would be unthinkable.

Bernard J. Carroll

Professor and Chairman Emeritus,

Department of Psychiatry,

Duke University Medical Center.

E-mail: bcarroll40@comcast.net

The writer is a former chairman of the Psychopharmacologic
Drugs Advisory Committee, Food and Drug Administration, U.S Public Health
Service.

Acknowledgment: Several colleagues
commented and made suggestions on drafts of this post – in particular John M.
Nardo, MD, Donald F. Klein, M.D., and Patrick Skerrett from STAT News.

Update 06-23-2016: This post was cross-posted on Naked
Capitalism, where some interesting comments can be found.

Monday, June 20, 2016

A thousand apologies - since the Society for
Medical Decision Making meeting in London, we have been traveling in the
UK, and I have been unable to find the time to post on the blog. But
in exchange we have caught up with good old friends, met lovely people,
and seen fabulous sights and beautiful country. I plan to return very soon, and then after much catching up, will then resume normal activity.

But a reminder - a comment on our latest post suggested that Health Care Renewal does good work, but requires more effort.

Yet, all our blog posts are
written by volunteers who have day jobs or are retired. At the moment,
we have no real budget, no paid staff, no investigators, no researchers,
no paid legal counsel, much less communications and public relations
specialists. If more effort is required, it may have to come from YOU,
dear readers. If you think that casting light on the issues we discuss
is important, and taking action to improve health care dysfunction is
more important, YOU also need to do something.

Of course,
we would greatly appreciate contributions to FIRM - the Foundation for
Integrity and Responsibility in Medicine, the tiny non-profit
organization which we formed to provide support to the blog and similar
dissemination, education and advocacy efforts to address health care
dysfunction. FIRM is a US 501(c)3 non-profit and so contributions are
deductible in the US to the extent provided by law. You can send
contributions to FIRM at 16 Cutler St, Suite 104, Warren, RI, 02885,
USA. Or email me (info at firmfound dot org) with questions.

If FIRM had real money,
maybe we could develop a staff and do a lot more to shine light on the
dark side. However, what is really required is effort by more than one
organization and a few volunteer bloggers. Consider doing something
yourself. Write a guest blog post for us, start your own blog, write a
letter to the editor, an op-ed, or a journal article. Write your
legislator. Meet with your legislator's staff. Organize a group of
like minded people and do something organized. If you are a health
professional, try to do your work in a way that will address health care
dysfunction.

Howwever, do not expect it to be easy. There
are many people personally enriching themselves through the current
system. They will do all they can to preserve the status quo. They may
command vast marketing, public relations, lobbying, and legal resources
(all ultimately paid using other peoples' - often your - money) to
maintain the status quo.

Saying something to combat the anechoic effect
is hard. Doing something is harder. But if we don't do something, it
will all get worse.

In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.

the scale of corruption is vast in both rich and poor countries.

Also,

Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.

The report did not get much attention. Since then, health care corruption has been nearly a taboo topic in the US. When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects benighted less developed countries. On Health Care Renewal, we have repeatedly asserted that health care corruption is a big problem in all countries, including the US, but the topic remains anechoic.

Yet somehow, a substantial minority of US citizens, 43%, seemed to believe that corruption is an important problem in US health care, according to a TI survey published in 2013 (look here). But that survey was largely ignored in the media and health care and medical scholarly literature in the developed world, and when it was discussed, it was again in terms of results in less developed countries. Health Care Renewal was practically the only source of coverage in the US of the survey's results.

Transparency International's New Report on Corruption in the Pharmaceutical Sector

Now Transparency International (TI) has tried, and Health Care Reenewal will try again. In June, 2016 Transparency International published a new report entittled

Within the health sector, pharmaceuticals stands out as sub-sector that is particularly prone to corruption. There are abundant examples globally that display how corruption in the pharmaceutical sector endangers positive health outcomes.

In my humble opinion, the report is particularly significant in that it classifies as corrupt various kinds of activities that occur within the pharmaceutical sector (and also in other parts of health care) which are often discussed publicly as anything from standard operating procedure through unfortunate errors to unethical behavior. These include many activities which we have frequently discussed on Health Care Renewal. For example,

We have frequently discussed how pharmaceutical companies, and biotechnology, medical device, and other health care companies and organizations, may manipulate clinical research to enhance the likelihood that is results will favor their products and marketing goals, even if the results are biased, inaccurate, could mislead physicians and patients, and ultimately harm patients. The TI report included:

As
pharmaceutical companies rely on gaining market entry in order to recoup R&D costs, when there is a lack of oversight in clinical trial data publication a conflict of interest exists in which a pharmaceutical company may have an incentive to manipulate clinical trial data. When clinical trial data is manipulated medical literature can become biased with positive findings fabricated, positive findings exaggerated or negative results hidden. This can result in inadequate prescribing patterns because HCPs rely on clinical trial data to make decisions on which medicines to use to treat patients.

We have frequently discussed how health care organizations (as above) may outright suppress clinical research when the results fail to support their interests. The TI report included:

Transparency and access to information through mandatory clinical trial registration, sanctions for not registering results or providing clinical trial information, and the publication of both positive and negative results are commonly discussed as helpful tools to curb corruption. With the European Medicines Agency (EMA) as a notable positive exception, public agencies and authorities do not require R&D-based pharmaceutical companies to make their raw data publicly available, making it impossible to verify whether the reported results are accurate. Based on laws and regulations clinical trial data is considered to be proprietary information, which allows pharmaceutical companies to conceal important data from the public domain.

Manipulation of the Dissemination of Clinical Research

We have frequently discussed how health care organizations may manipulate the dissemination of clinical research, through various forms of publications, presentations, courses, media summaries, etc, to favor their products and marketing goals, even if the results are misleading and could harm patients. For example, a while back we discussed the problem of "ghost-written" articles appearing in scholarly journals. The TI report included:

The practice of ghostwriting is also a risk with clinical trials. Ghostwriting involves the writing of clinical trial publications by industry and then having a highly esteemed researcher pass these findings off as their own without disclosing their actual involvement with the authorship of the article. It is a common practice, particularly in industry led trials. Ghostwriting is done to increase the prestige and reputation of the findings, while simultaneously researchers are able
to improve their reputation, which can lead to promotions. Clearly this practice can result in inaccurate results being published.

Deceptive Marketing

We have frequently discussed how marketing of pharmaceuticals (and nearly everything else in health care) may be deceptive, favoring companies' products and services, but again misleading health care professionals and patients, and ultimately risking patient harm. In the extreme, pharmaceutical companies (and other health care organizations) may resort to bribes or kickbacks. The TI report included:

There are several methods for a corrupt pharmaceutical company to unethically market its medicines. At its most simple a pharmaceutical company can bribe a HCP directly with payments so its medicines are more likely to be prescribed. More abstrusely individuals may include a pharmaceutical company’s medicine on the national list that is reimbursed by public funds, in return for an indirect bribe by being sent to inappropriate holiday destinations for lavish conferences.

Corrupt marketing practices also include pharmaceutical companies providing misleading
information regarding the safety and efficacy of a medicine to influence doctors’ prescribing habits and encouraging off-label, unlicensed use to increase sales.

Again, while the report summarizes information that is likely familiar to most Health Care Renewal readers, what is striking is that it describes manipulation of clinical research, suppression of clinical research, manipulation of dissemination of clinical research, and deceptive marketing as corruption. That is a sentiment rarely heard in the US, and one that appears nearly taboo.

Demonstrating the strength of the taboo, this striking report has gotten almost no attention in the media or scholarly medical and health care literature in the developed English-speaking countries. Let me note the important exceptions, however.

I learned of the report from a brief news item from the BMJ, the prestigious UK journal that seems most at the forefront of championing the integrity of medical and health care research.(1) The only substantial news article I could find on the report was also from the UK, in the Independent. Its sub-title is worth repeating:

Transparency International says corruption is making a few rich and wrecking the health of some of the world's poorest people

The report itself suggests why it has been so anechoic, just like nearly every other attempt to expose health care corruption to public discussion. Essentially, there is so much money to be made through pharmaceutical (and by implication, other health care corruption) that the corrupt have the money, power, and resources to protect their wealth accumulation by keeping it obscure. In the TI Report itself,

However, strong control over key processes combined with huge resources and big profits to be made make the pharmaceutical industry particularly vulnerable to corruption. Pharmaceutical companies have the opportunity to use their influence and resources to exploit weak governance structures and divert policy and institutions away from public health objectives and towards their own profit maximising interests.

Keep in mind that the money made from corruption does not just go to innocent peoples' retirement funds that are invested in pharmaceutical stocks. It predominantly goes to top corporate executives and managers, and their cronies who preside over the corrupt practices.

If we are not willing to even talk about health care corruption, how will we ever challenge it?

So to repeat an ending to one of my previous posts
on health care corruption.... if we really want to reform health care,
in the little time we may have
before our health care bubble bursts, we will need to take strong action
against health care corruption. Such action will really disturb the
insiders within large health care organizations who have gotten rich
from their organizations' misbehavior, and thus taking such action will
require some courage. Yet such action cannot begin until we acknowledge
and freely discuss the problem. The first step against health care
corruption is to be able to say or write the words, health care
corruption.

Reference

1. Torjesen I. Group calls for more to be done to tackle corruption in the pharmaceutical industry. BMJ 2016;353:i3099. Link here.

Your
smartphone allows you to get almost instantaneous answers to the most
obscure questions. It also allows you to waste hours scrolling through
Facebook or looking for the latest deals on Amazon. More
powerful computing systems can predict the weather better than any
meteorologist or beat human champions in complex board games like chess.

But
for several years, economists have asked why all that technical
wizardry seems to be having so little impact on the economy. The issue surfaced again
recently, when the government reported disappointingly slow growth and
continuing stagnation in productivity. The rate of productivity growth
from 2011 to 2015 was the slowest since the five-year period ending in
1982.

Healthcare becomes the gravamen of the article:

One place to look at this disconnect is in the doctor’s office. Dr.
Peter Sutherland, a family physician in Tennessee, made the shift to
computerized patient records from paper in the last few years. There are
benefits to using electronic health records, Dr. Sutherland says, but
grappling with the software and new reporting requirements has slowed
him down. He sees fewer patients, and his income has slipped.

Unfortunately, the advisors who helped him with the article may have provided incomplete information:

... “The government funding has made a huge difference,” said Dr. Ashish
Jha, a professor at the Harvard School of Public Health. “But we’re
seeing little evidence so far that all this technology has had much
effect on quality and costs.”

... "I'm not suggesting EHR is going to be a panacea, but the one thing that is absolutely true is there is nothing else out there now that has any more political appeal," Jha says. "Everybody agrees, whether you are a conservative, moderate, or liberal, that we have to do something about healthcare. So the one place where we can all come to agreement is we have to do something about electronic records."

I do not think "political appeal" is a good justification for a multi-billion dollar cybernetic experiment in medicine, where the risks of the technology are considerable and where basic healthcare needs are not being well met among the poor and underprivileged.

Former ONC Chair David Brailer is quoted:

“People confuse information automation with creating the kind of work
environment where productivity and creativity can flourish,” said Dr.
David J. Brailer, who was the national health technology coordinator in
the George W. Bush administration. “And so little has gone into changing
work so far.”

Brailer was little better than Jha, and moves the goalposts with a type of circular logic. He appears to be saying that technology that will revolutionize medicine can't work until we change
how things are done in medicine so the technology can revolutionize medicine.

The article then quotes one Tennessee physician, a Dr. Sutherland, who is "happy" to accept bad health IT, a resultant pay cut, and increased work:

... Today,
Dr. Sutherland’s personal income and the medical group’s revenue are
about 8 percent below where they were four years ago. But in 2015, both
his earnings and the revenue of Healthstar, which employs 350 people in
10 clinics, increased slightly, by nearly 3 percent from 2014.

... Dr.
Sutherland bemoans the countless data fields he must fill in to comply
with government-mandated reporting rules, and he concedes that some of
his colleagues hate using digital records. Yet
Dr. Sutherland is no hater. Despite the extra work the new technology
has created and even though it has not yet had the expected financial
payoff, he thinks it has helped him provide better information to
patients.

He
values being able to tap the screen to look up potentially harmful drug
interactions and to teach patients during visits. He can, for example,
quickly create charts to show diabetes patients how they are progressing
with treatment plans, managing blood glucose levels and weight loss.

He
is working harder, Dr. Sutherland says, but he believes he is a better
doctor. Blunt measures of productivity, he added, aren’t everything. “My
patients are better served,” he said. “And I’m happier.”

While being able to provide fancy charts and check drug-drug interactions (for which a massive and expensive EHR is certainly not needed; a PDA will suffice) is fine.

However, anyone who gladly
accepts a pay cut, and inconvenience, and harder work due to bad health IT, and is a happy camper with that
state of affairs, either suffers from the Stockholm syndrome or has a lot of discretionary income and free time to spare that many clinicians do not.

You should be aware of the letter's contents. I've also attached it to this email.

In academic Medical Informatics, such matters are often ignored, as they
run contrary to the narrative that IT will "revolutionize medicine"; I
know, as I was Yale faculty in Medical Informatics myself.

The
assumption in academic circles and in the Administration (unfortunately) is that "all health IT is good health IT."

Good Health
IT ("GHIT") is defined as IT that provides a good user
experience, enhances cognitive function, puts essential information as
effortlessly as possible into the physician’s hands, can be easily, substantively
and cost-effectively customized to the needs of medical specialists and
subspecialists, keeps eHealth information secure, protects patient privacy and
facilitates better practice of medicine and better outcomes.

Bad Health IT ("BHIT") is defined as IT that is ill-suited to
purpose, hard to use, unreliable, loses data or provides incorrect data, is
difficult and/or prohibitively expensive to customize to the needs of different
medical specialists and subspecialists, causes cognitive overload, slows rather
than facilitates users, lacks appropriate alerts, creates the need for
hypervigilance (i.e., towards avoiding IT-related mishaps) that increases
stress, is lacking in security, is lacking in evidentiary soundness, compromises patient privacy or otherwise
demonstrates suboptimal design and/or implementation.

It comes as no surprise not to find productivity gains, but instead hundreds of thousands of angry physicians (and nurses), when health IT is mostly bad IT.

The health IT industry itself needs serious remediation before its products will be a boon to medicine.

Friday, June 03, 2016

Since the 1990s, clinicians have been exhorted to follow clinical practice guidelines (CPGs) to improve their decision-making and patients' outcomes. When Dr Wally Smith and I started teaching a short course (often at the Society for Medical Decision Making meetings) about changing physician behavior, we naively set out to improve decisions by increasing adherence to such guidelines. We first thought that physicians' apparent shortcomings in guideline adherence were due to their lack of knowledge of the guidelines and the underlying evidence, and to their human cognitive limitations.

That approach, however, failed to yield ways to improve adherence. After a while, it occurred to us that there might be other reasons physicians did not follow guidelines, including their lack of trust of the guidelines or the evidence supposedly incorporated within them. We learned that integrity of the clinical evidence base has been severely degraded due to the manipulation of clinical studies by those with vested interests, and the outright suppression of trials for which manipulation does not produce the desired results.

Furthermore, as we became less naive, we learned that the integrity of the guideline development process was also suspect, again due to the influence of those with vested interest. No wonder physicians were suspicious of guidelines, and resisted adhering to them.

In 2011, the prestigious Institute of Medicine released a report on the
development of better standards to produce more trustworthy guidelines
(Clinical Practice Guidelines We Can Trust. Link here.) We posted about that report here, but noted that it was receiving little other attention, an example of the anechoic effect. The IOM report cited conflicts of interest (COIs) affecting the guideline development process as a major reason such guidelines might be untrustworthy, and suggested a variety of ways to reduce COIs affecting guidelines.

These included in particular:
- Guideline committee members should disclose their conflicts of interest in detail, and these should appear in the guidelines (Standard 2.1, 2.2)
- The number of conflicted committee members should be minimized, and in no case should be a majority of the committee (2.3, 2.4)
- Funders should have no role in guideline development (2.4)

This week, an original article(1) and editorial(2) in PLoS Medicine discussed how guidelines published since the report was produced addressed conflicts of interest.

Article Summary

Below I summarized the article, but presented results somewhat differently than did the authors.

Design

Campsall et al did a cross-sectional study of clinical practice guidelines that appeared in the US Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse in 2012 from national or international organizations, excluding guidelines produced by organizations restricted to allied health professionals, guidelines produced by corporations, or guidelines that had no specific recommendations. They obtained information from the guidelines, the organizations' websites, and surveys sent to the organizations.

Study Population

The study population was 290 guidelines produced by 95 organizations. The response rate for the surveys was 68%. The organizations were primarily professional societies (67%) or disease advocacy groups (21%).

63% of organizations reported receiving funds from biomedical companies. (It was not clear whether the remainder denied receiving such funding, or provided no information about funding.)

My comment is that the majority of such ostensibly "do-gooder" organizations are nonetheless at least somewhat supported by commercial firms that market health care products, presumably mainly drugs or devices.

Conflict of Interest Policies

Please note that the authors provided results to emphasize the positive, for example, they provided the proportion of organizations which provided specific types of information about COIs or had particular policies to reduce COIs. In most cases, I simply did subtractions to emphasize the negative. Furthermore, the authors further emphasized the positive by choice of denominator, as noted below.

20% of organizations did not provide any information about conflict of interest policies, and 7% asserted the existence of such policies, but did not disclose them. A majority, 55%, did not have disclosed policies that specifically dealt with with conflicts of interest affecting guidelines.

My comment is thus that a majority of these do-gooder organizations did not apparently even begin to address, at least in terms of clear, transparent written policy, the recommendations of the IOM report on trustworthy guidelines.

Measures to Improve Guidelines Trustworthiness by Decreasing Influence of Conflicts of Interest

The authors provided the number of organizations with disclosed policies that addressed particular issues of concern to the IOM in their report on trustworthy guidelines, but made the proportions of such organizations seem larger by using as a denominator the number of organizations that disclosed their entire policies, rather than the total number of organizations which produced the guidelines.

Therefore, they found that of the 60 (out of 95 total) organizations that fully disclosed their conflict of interest policies:
98% required committee members to disclose conflicts of interest;
90% required review of conflicts of interest before guideline publication;
68% required that a majority of guideline committee members be free of conflicts of interest;
92% reported publishing committee members' conflicts of interest within guidelines;
78% did not allow direct industry funding of guideline development
82% did not allow industry participation in selection of committee members
67% did not allow industry to review guidelines prior to publication.

That all sound good, but consider what happens when one uses the total sample of organizations in the denominators.

Therefore, the article also found that of all 95 organizations that produced the guidelines of interest:

38% did not require CPG committee members to disclose conflicts of interest
43% did not require review of committee members' conflicts of interest prior to guidelines development
57% did not require that a majority of guideline committee members be free of conflicts
44% did not report publishing committee members' conflicts of interest within guidelines
48% did not report preventing direct industry funding of guidelines
51% did not report preventing industry participation in selection of committee members
61% did not report preventing industry review of guidelines prior to publication.

My comment is that thus the results suggested that substantial numbers of organizations that produced CPGs did not demonstrate that they were committed to measures that would improve guidelines trustworthiness by reducing the influence of conflicts of interest.

Disclosure of Conflicts of Interest Within Guidelines

Again, it was necessary to recalculate some proportions using the full population of guidelines reviewed as the denominator.

Of the 290 guidelines reviewed:
65% "included disclosure statements regarding direct funding and support"
37% specifically disclosed the absence or presence of direct funding from biomedical companies
However,
49% did not disclose committee members' financial relationships
99% did not disclose relevant financial relationships of the organization (that is, institutional conflicts of interest) that produced the guidelines as a whole

My comment is that substantial numbers of published guidelines were not clearly produced so as to increase their trustworthiness by reducing the influence of conflicts of interest on them.

Did the Guidelines Follow the Organizations' Stated Policies?

The authors commendably provided information about whether the guidelines produced by organizations that disclosed conflict of interest policies followed those polices. They found:

16% of organizations "that reported that committee member conflicts of interested were published in guidelines" produced guidelines that did not include committee members' COI disclosure

61% of organizations that "reported the majority of committee members must be free of conflicts of interest" produced guidelines by committees with majorities of conflicted members

6% of organizations that "reported that industry partners were not permitted to directly fund clinical practice guideline development" produced guidelines which disclosed such funding.

My comment is that thus even of the organizations that stated they had policies in place to improve the trustworthiness of the guidelines they produced by reducing the influence of conflicts of interest, they allowed guidelines to be produced that did not follow those policies.

Authors' Conclusion

Financial relationships between organizations that produce clinical practice guidelines and the biomedical industry appear to be common. These relationships are important because they may influence, through guideline usage, the practice of large numbers of healthcare providers. We believe that to effectively manage conflicts of interest, organizations that produce clinical practice guidelines need to develop robust conflict of interest policies that include procedures for managing violations of the policy, make the policies publicly available, and disclose all financial relationships with biomedical companies.

Editorialists' Conclusion

The editorial by Bastian(2) was sharper in tone. It included an observation that reinforced my confession of naivete above:

With hindsight, I think those of us encouraging better methodology for guideline development in the 1990s took the issue of disclosure of financial interests too much for granted. It seemed so self-evident, it got barely a mention even in national policy on guideline development

She also noted that the Campsall study did not address all the ways conflicts of interest can influence guideline development:

Stelfox and colleagues focus particularly on the organizational conflicts of interest of guideline producers and their policies. They examine the financial interests of the organizations, but not of the individuals employed within those organizations. This same blind spot is evident when it comes to policies about committee members; the financial interests of the organizations that individuals represent tend to be disregarded. Yet these can be substantial, including for patients’ organizations.

She noted that the failure of guidelines to report their developers' conflicts of interest is a continuing problem. The rate of failure to report found by Campsall et al was

about the same rate that Taylor and Giles found in 2004 and Norris and colleagues found in 2010.

Finally, she emphasized that we are still a long way from having guidelines that health care professionals and patients can trust:

Guideline processes without adequate financial conflict management have to become unacceptable to a far wider circle. They need to become unacceptable to influential committee members, to the medical journals that lend so many guidelines additional standing and reach, and to the membership of the professional societies that produce them. Until that happens, for guidelines as for clinical research, it’s a case of caveat lector: let the reader beware.

My Summary

So should physicians trust clinical practice guidelines? At least this article suggests they ought to be very very skeptical of them. The IOM report meant to improve the trustworthiness of practice guidelines seems to be honored mainly in the breach. The likelihood that any given guideline was produced so as to reduce the influence of conflicts of interest on it is low. Even organizations that ostensibly put professional values and patients first in their efforts to develop guidelines seem to often be financially beholden to companies that want to sell drugs and devices. Physicians and patients ought to be concerned that most new clinical practice guidelines may be as much about marketing commercial products as improving medical practice or patients' outcomes.

The current US presidential race has made it evident that we have a lot of disgruntled citizens, many of whom believe our system is rigged to favor the "establishment." I suggest that the more we know about clinical practice guidelines, the more it appears that the health care system is rigged to favor certain parts of the "establishment," the big corporations that market drugs and devices, and their paid part-time hands within medical societies and patient advocacy groups who have turned these ostensibly idealistic, do gooder organizations into part-time marketing machines.

The huge and complex web of individual and institutional conflicts of interest that binds much of the health care system, the government, and industry may be good for the insiders, but is stifling improvement in our dysfunctional health care system. True health care reform would first expose these conflicts, then reduce or better yet, eliminate them, and make health care more about helping patients and less about making money by marketing commercial products.

Musical Interlude

To dispel the darkness a bit, Paul Simon, "Still Crazy After All These Years," 1992 acoustic version:

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